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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San'Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distrito.. Job Address City t Size . Q:fJLQ1 PM _ Owner's Name Address — �.� t Phone _ #� Contractor's Name TYPE OF WELL/PUM177�� N�D. NEW WELL ` WELL REPLACEMENT ❑ -- PUMP INSTALLATION DESTRUCTION ❑ _ - 3x F SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE PE OF WELL PROBL"EM AREA CONSTRUCTION-SPI CIFICATIO S ❑ Industrial �— f Open Bottom ❑ Manteca Dia, of Well Excavation 6-1r: p� i Domestic/Private ❑ Gravel Pack Dia..of Well Casing- ❑ Public C1 Other ❑ Tracy Type of Casing Specifications /U ❑ Delta r ,. Depth of-Grout Seal _� Type of Grout ❑ Irrigation QUQApprox. Dep h ❑ Eastern Repair Work Done ❑ Type of Pump H P ]S urfaceiSeaPfnstalled by.: Well Destruction ❑ Well Diameter State Work Done Sealing Materia! (top 50') ' Depth �Filler-Material-(.Below_W) TYPE OF SEPTIC WORK.: NEWINSTAL REPAIR/ATIO [I D DDIN ES0 TRUCTION (Ne septic system permitted it public sewer s Installation will sery Residence , Commercial! Otheravailable within 200 feet.) � _ Number of living units: Number of bedrooms_� � 1 Character of soil to a depth feet: SEPTIC TANK ❑ Type „�,�. Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments f w ,r� I ' � Method of Disposal � Distance to nearer . Well Fo tion_�� Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDTotal length/size f� ` ❑ Distance to nearest: ell Foundation Property Line / SEEPAGE PITS ❑ Depth '�' p Size � Number.. SUMPS ❑ `Dista to nearest: Wep DISPOSAL PONDS L3,_ Foundation 0.1. Property Line h I hereby certify that I have prepared this application and that the work will be done in accordance ith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquir► Local Health District. Home owner or licensed agent's signature certifies the following: � employ an g "I certify that in the performance of the work for which this permit is issued, I shall not P Y Y person in such manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature i certifies the following:"I certify that in the performance of the work for which this tion laws of California." r, .. _ I I permit is issued, I shall employ persons subject to workman's compensa- The applicant mu II for required inspections. Complete on reverse side. Signed e: ,r 1 Titlr Date: f y FOR DEPARTMENT USE`ONLY Application Accepted by Date D- ay r_a Pit or rout spection by � _Dato It?�� _ Final'I coon by _ Date--L 12-1%1 Additional Comments: n ❑ Stk 466 67g1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 p Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r f Fee . INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'N0. + EH 1324(REV.10l113F EH 1426 - 0 5• 0-z f 3 O